RELATED CHAPTER

AMENDMENT

In September 2017 this chapter was updated with information about the four types of FGM as defined by WHO. Links have been added to both the new Home Office FGM protection orders factsheet and to the guidance to the 'Statement opposing female genital mutilation' (often referred to as a health passport).

1. Introduction

The World Health Organisation (WHO) defines female genital mutilation (FGM) as: "all procedures that involve partial or total removal of the external female genitalia, or other injury to the female genital organs for non-medical reasons" (WHO, 2014). FGM is physical abuse, and it is also a form of sexual violence.

The Female Genital Mutilation Act was introduced in 2003 and came into effect in March 2004. The Act:

Makes it illegal to practice FGM in the UK;

Makes it illegal to take girls who are British nationals or permanent residents of the UK abroad for FGM whether or not it is lawful in that country;

Makes it illegal to aid, abet, counsel or procure the carrying out of FGM abroad;

Has a penalty of up to 14 years in prison and/or a fine.

This applies to any UK national or permanent resident convicted of carrying it out, or aiding and abetting the process, while in the UK or overseas.

A person is guilty of an offence if they excise, infibulate or otherwise mutilate the whole or any part of a girl’s labia majora, labia minora or clitoris. A person is guilty of an offence if they aid, abet, counsel or procure a girl to excise, infibulate or otherwise mutilate the whole or any part of her own labia majora, labia minora or clitoris. For the purposes of this legislation, “girl” includes “woman”.

FGM is recognised internationally as a violation of the human rights of girls and women. It reflects deep-rooted inequality between the sexes, and constitutes an extreme form of discrimination against women. It is nearly always carried out on minors and is a violation of the rights of children. The practice also violates a person's rights to health, security and physical integrity, the right to be free from torture and cruel, inhuman or degrading treatment and the right to life when the procedure results in death.

FGM has been classified by the World Health Organisation (WHO) into four types:

Type 1 – Clitoridectomy: partial or total removal of the clitoris (a small, sensitive and erectile part of the female genitals) and, in very rare cases, only the prepuce (the fold of skin surrounding the clitoris);

Type 2 – Excision: partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (the labia are the ‘lips’ that surround the vagina);

Type 3 – Infibulation: narrowing of the vaginal opening through the creation of a covering seal. The seal is formed by cutting and repositioning the inner, or outer, labia, with or without removal of the clitoris; and

2. Impact of FGM on Women and Girls

FGM has no health benefits, and it harms girls and women in many ways. It involves removing and damaging healthy and normal female genital tissue, and interferes with the natural functions of girls' and women's bodies.

3. Who is at Risk?

FGM is mostly carried out on young girls sometime between infancy and age 18, and occasionally on adult women, in some cases on young women before marriage or pregnancy (and between pregnancies). In Africa, more than 3 million girls have been estimated to be at risk of FGM annually. More than 125 million girls and women alive today have been cut in African, Asian and Middle Eastern communities where FGM is concentrated.

The practice is most common in the western, eastern and north-eastern regions of Africa, in some countries in Asia and the Middle East and among migrants from these areas.

The causes of female genital mutilation include a mix of cultural, religious and social factors within families and communities.

It is important to note the causes are different across the countries who practise FGM but they can include:

Where FGM is a social convention, the social pressure to conform to what others do and have been doing is a strong motivation to perpetuate the practice;

FGM is often considered a necessary part of raising a girl properly, and a way to prepare her for adulthood and marriage;

FGM is often motivated by beliefs about what is considered proper sexual behaviour. FGM is used as a way of increasing family honour by demonstrating a woman’s virginity on her wedding night;

FGM is associated with cultural ideals of femininity and modesty, which include the notion that girls are “clean” and "beautiful" after removal of body parts that are considered "male" or "unclean";

Though no religious scripts prescribe the practice, practising communities often believe the practice has religious support. Religious leaders take varying positions with regard to FGM: some promote it despite its illegality, some consider it irrelevant to religion and others contribute to its elimination;

Local structures of power and authority, such as community leaders, religious leaders, persons who cut or circumcise and even some medical personnel can contribute to upholding the practice;

Enhancing fertility;

Increasing sexual pleasure for the male.

4. Responding to FGM

The appropriate response to FGM is to follow usual safeguarding procedures to ensure:

Immediate protection and support for the girl;

That the practice is not perpetuated.

There are three circumstances relating to FGM which require identification and intervention:

Where a girl is at risk of FGM;

Where a girl has been abused though FGM;

Where a prospective mother has undergone FGM.

Indications that FGM may be about to take place include:

The family comes from a community that is known to practise FGM;

A girl may talk about a long holiday to her country of origin or another country where the practice is prevalent, including African countries and the Middle East;

A girl may confide to a professional that she is to have a “special procedure” or to attend a special occasion;

A girl may request help from a teacher or another adult;

Any girl born to a woman who has been subjected to FGM must be considered to be at risk, as must other female girls in the extended family;

Any girl who has a sister who has already undergone FGM must be considered to be at risk, as must other girls in the extended family.

Indications that FGM may have already taken place include:

A girl may spend long periods of time away from the classroom during the day with bladder or menstrual problems if she has undergone Type 3 FGM;

A prolonged absence from school with noticeable behaviour changes on the girl's return could be an indication that a girl has recently undergone FGM;

Professionals also need to be vigilant to the emotional and psychological needs of girls who may be/are suffering from the adverse consequences of the practice (e.g. withdrawal, depression etc.);

A girl may require to be excused from physical exercise lessons without the support of her GP;

A girl may ask for help.

An appropriate response to a girl suspected of having undergone FGM, as well as a girl at risk of undergoing FGM, could include:

Arranging for an interpreter if this is necessary and appropriate – DO NOT AGREE to friends/family members interpreting on their behalf, because the pressure for FGM usually comes from these parties and the girl may not feel able to disclose what’s happening or may feel pressure not to disclose. Also, there may be an associated risk of current/potential domestic violence, honour-based violence, forced marriage, or the risk of the FGM procedure being expedited in the case of a girl at risk;

Understanding how she may feel in terms of language barriers, culture shock, that she, her partner, her family are being judged;

Creating an opportunity for the girl to disclose – seeing the girl on her own;

Using simple language and asking carefully worded questions;

Using terminology that the girl will understand – do not use the term “female genital mutilation” or “FGM” as the girl is unlikely to know what this means;

Being sensitive, respectful and willing to listen – the girl is likely be loyal to her parents;

Giving the girl time to talk because of the intimate nature of the subject;

Getting accurate information about the urgency of the situation if the girl is at risk of being subjected to the procedure;

Giving the message that the girl can come back to you again;

Giving a clear explanation that FGM is illegal and that the law can be used to help the family avoid FGM if/when they have daughters;

FGM is illegal but a non-judgemental approach to the girl/woman must be taken.

5. Recording FGM

The Department of Health 2014 statement to healthcare professionals sets out the current requirements of NHS staff in relation to FGM:

It is mandatory to record FGM in a patient’s healthcare record;

Following publication of the Data Standard on 2nd April 2014, it became mandatory for any NHS healthcare professional to record within a patient’s clinical record if they identify through the delivery of healthcare services that a woman or girl has had FGM.

Information Sharing

Information relating to safeguarding concerns should routinely be shared with other key professionals within the child’s life. In practice this means that concerns identified should be shared with the patient’s GP and her Health Visitor (HV) or School Nurse (SN), depending on the age of the child who is potentially at risk of FGM;

Regulated health and social care professionals and teachers are required to report cases of FGM in girls under 18s which they identify in the course of their professional work to the police.

They are required to phone the police non-emergency crime number, 101, if a girl under 18:

Tells you she has had FGM (female genital mutilation);

Has signs which appear to show she has had FGM.

This is a personal duty; the professional who identifies FGM / receives the disclosure must make the report.

Purpose and Audience

The duty applies to all regulated professionals (as defined in Section 5B(2)(a), (11) and (12) of the 2003 Act) working within health or social care, and teachers. It therefore covers:

Health and social care professionals regulated by a body which is overseen by the Professional Standards Authority for Health and Social Care (with the exception of the Pharmaceutical Society of Northern Ireland). This includes those regulated by the:

General Chiropractic Council;

General Dental Council;

General Medical Council;

General Optical Council;

General Osteopathic Council;

General Pharmaceutical Council;

Health and Care Professions Council (whose role includes the regulation of social workers in England);

Nursing and Midwifery Council.

Teachers - this includes qualified teachers or persons who are employed or engaged to carry out teaching work in schools and other institutions.

Who does not officially have to comply with the duty?

Employees who are not regulated do not have to comply with the duty.

This includes nursery nurses, healthcare assistants.

Local Procedures Reporting to 101

The Leicester, Leicestershire and Rutland LSCBs have taken the decision that all practitioners regardless of their regulatory status must if a girl under 18:

7. Referral Process

As FGM is a form of child abuse, professionals have a statutory obligation under national safeguarding protocols (e.g. Working Together to Safeguard Children 2015) to protect girls and women at risk.

Any information or concern that a girl is at immediate risk of FGM, or going abroad to undergo FGM, should result in an immediate Referrals to Children’s Social Care and the Police. Practitioners should be alert to the need to act quickly – before the girl is abused through the FGM procedure in the UK or taken abroad to undergo the procedure.

If the event is imminent the police should be contacted without delay. Where FGM has been carried out or is imminent of being practised, the Police Child Abuse Investigation Team (CAIT) will take a lead role in the investigation of this serious crime, working to common joint investigative practices and in line with strategy agreements.

Practitioners should follow their agency’s supervisory arrangements with regards to undertaking referrals to social care. This may include a discussion with their Designated Safeguarding Lead (DSL) or line manager unless this unnecessarily delays the process. If the practitioner has contacted the police or Children’s Social Care as an urgent matter, they should inform/consult their Designated Safeguarding Lead (DSL) or line manager as soon as possible in line with their agency’s supervisory arrangements with regards to undertaking referrals to social care.

If the referral is concerning one girl, consideration must be given to whether sisters or other female extended family members such as cousins are also at similar risk. When concerns are raised about FGM there should be consideration of possible risk to other girls in the practising community. Practitioners should be alert that any girl in this community could be at risk of FGM and will then need to be referred, keeping in mind the caution that must be exercised when dealing with a practising community, as referrals may alert the community that Children’s Social Care and the police are aware that they are practising FGM and this may heighten the risk for this girl and other girls in the community.

The consent of the girl or her family is not necessary if the girl or other girls are at risk of significant harm through FGM.

7.1 Adult Disclosure of FGM

There is no requirement for automatic referral of adult women with FGM to adult social services or the police.

Healthcare professionals should be aware that a disclosure may be the first time that a woman has discussed her FGM with anyone. Referral to the police must not be introduced as an automatic response when identifying adult women with FGM, and each case must continue to be individually assessed. The healthcare professional should seek to support women by offering referral to community groups for support, clinical intervention or other services as appropriate: for example, through an NHS FGM clinic. The wishes of the woman must be respected at all times.

A woman may disclose that she has undergone FGM in the past and would like to access support and/or services. This should be treated in the same way as any disclosure of historical abuse. For more information see Historical (non recent) Abuse Allegations. If the woman discloses information that suggests the practice is continuing and that girls in her family or community are at risk of FGM, a referral needs to be made. If the adult victim was born in the UK and FGM has been carried out recently, or where she has attended for a second or subsequent child and FGM has been carried out on her again, then professionals need to consider a referral as both these cases are criminal offences. See Section 6, Referral Process.

7.2 Risk Assessment of Adult Victims of FGM

Where an adult makes a disclosure of FGM, the Risk Assessment Form Part One (B) Non Pregnant Adult Women: Female Genital Mutilation Risk and Safeguarding. Guidance for professionals Department Health 2015 (Appendix 1) is to be completed to determine the level of risk and whether a referral to Children’s Social Care is required.

7.3 Pregnant Women disclosing FGM

If the woman is pregnant, the welfare of her unborn child or others in her extended family must be considered at this point, as these children are potentially at risk and safeguarding action must be taken accordingly. Risk Assessment Form Part One (a) Pregnant Women: Female Genital Mutilation Risk and Safeguarding. Guidance for professionals Department Health 2015 (Appendix 1) is to be completed to determine the level of risk and whether a referral to Children’s Social Care is required.

However if the family are already known to social care services and FGM is known or identified within the family then the referral must be made (regardless of the outcome of the risk assessment).

After a woman has given birth, the healthcare professional must include information about her FGM status, including the risk assessment guidance and, where completed, the referral form to Children’s Social Care in the discharge summary record sent to the GP and Health Visitor. This is whether the information is identified within a maternity setting, in an accident and emergency department, within a travel clinic or any other healthcare setting. GPs and HV/SNs themselves should not forget to routinely share information themselves; if risks are identified within the GP practice, this should be shared with the HV/SN, and vice versa.

8. Strategy Meeting / Discussion

8.1 A Girl is at Risk of FGM

A Strategy Meeting (or Strategy Discussion held over the phone due to immediacy of concerns) must be convened within 2 working days of receipt of referral, or sooner if the matter is urgent. For more information, see Strategy Discussions Procedure. The meeting should involve representatives from the police, Children’s Social Care, education, health and voluntary services. Health providers or voluntary organisations with specific expertise (e.g. FGM, domestic abuse) must be invited and consideration must also be given to inviting a legal advisor.

The Strategy Meeting should establish if the parents or girl has had access to information about the harmful aspects of FGM and the law in the UK. If not, this information should be shared with them. Consideration must be given to any sisters or other female children living in the family who may be at risk.

The Strategy Meeting should be fully minuted, determine risk and plan the way forward. Consideration should be given how best to work with the family and community organisations to ensure the safety of the girl and other girls in the community. The use of an appropriately trained female interpreter (not related to the family) should be considered.

If the Strategy Meeting decides that the girl is in immediate danger of mutilation and parents cannot satisfactorily guarantee that they will not proceed with it, then an Emergency Protection Order should be sought. If any legal action (care proceedings or criminal proceedings) is being considered, legal advice must be sought.

8.2 A Girl has already undergone FGM

If the girl has already undergone FGM, a Strategy Meeting must be convened within 2 working days and will need to consider carefully whether to continue enquiries or whether to assess the need for support services and/or therapeutic and medical services.

The Strategy Meeting will consider how, where and when the procedure was performed and the implication of this. If the girl has already undergone FGM, the Strategy Meeting will consider carefully whether to continue enquiries or whether to assess the need for support services.

Where FGM has been carried out, the Police Child Abuse Investigation Team (CAIT) will take a lead role in the investigation of this serious crime, working to common joint investigative practices and in line with strategy agreements.

9. Child Protection Enquiries

Every attempt should be made to work with parents on a voluntary basis to prevent the abuse. It is the duty of the investigating team to look at every possible way that parental co-operation can be achieved, including the use of community organisations and/or community leaders to facilitate the work with parents/family. However, the girl’s interest is always paramount. See Section 47 Enquiries for more information.

An appropriately trained female interpreter (not related to the family) must be used in all interviews with the family. If no agreement is reached, the first priority is protection of the child and the least intrusive legal action should be taken to ensure the child's safety.

A second Strategy Meeting should be convened within 10 working days of the referral with the same chair. This meeting must evaluate the information collected in the enquiry and recommend whether a Child Protection Conference is necessary in line with Initial Child Protection Conferences. A Child Protection Conference should only be considered necessary if there are unresolved child protection issues when the initial investigation and assessment have been completed. A girl who has undergone FGM should not normally be subject to a Child Protection Conference or made subject to a Child Protection Plan unless additional child protection concerns exist.

However the girl should be offered counselling and medical help. Services to the girl and her family can be offered through Early Help Assessment or as a Child in Need.

10. Responding to FGM – The Role of Health Practitioners

Healthcare professionals in general practice, sexual health clinics and maternity services are the most likely to encounter a girl or woman who has been subjected to FGM.

Healthcare professionals encountering a girl or woman who has undergone FGM should be alert to the risk of FGM in relation to her:

Sisters;

Daughters or daughters she may have in the future;

Extended female family members, including cousins and grand-daughters.

All girls/women who have undergone FGM should be given information about the legal and health implications of practising FGM. Following consultation with the girl/woman on their individual circumstance, and with their agreement, consideration should be given to providing information to their boyfriend, partner or husband as appropriate. Any potential impact of this on the girl or woman should be taken into account before pursuing this further, because there is a risk of domestic violence, honour-based violence and FGM procedure being expedited if a disclosure is made to other family members. Each woman should be offered counselling to address how things will be different for her afterwards.

Information about a girl or woman who has undergone or is at risk of FGM should be clearly recorded in the notes (and, where possible, diagrammatically) recorded by maternity and health visiting professionals, GPs and practice nurses.

If a girl or woman who has been de-infibulated requests re-infibulation after childbirth, health professionals should ensure the mother receives appropriate information about the legal and health implications of practising FGM.

Health professionals should complete the DoH FGM Risk Assessment. Where the FGM Risk Assessment identifies 'significant or immediate risk' a referral must be made to Children's Social Care.

11. Responding to FGM – The Role of Education / Leisure / Community / Voluntary and Faith Groups

Teachers, other school staff, volunteers and members of community groups may become aware that a girl is at risk of FGM through her disclosure or her disclosure to another child or young person, or a parent/other adult about the procedure being planned or that it has already happened to an older girl in the family.

Nursery nurses and school nurses are in a particularly good position to identify FGM or receive disclosure about it. A professional, volunteer or community group member who has information or suspicions that a girl is at risk of FGM should consult with their agency’s designated safeguarding lead (if they have one) or should make a Referral to Children’s Social Care in line with Section 6, Referral Process of this procedure. If the girl appears to be in acute physical and/or emotional distress, or the plans for FGM appear to be imminent, they should make an immediate Referral to Children’s Social Care or the Police.

Professionals in all agencies must record information about FGM which may be relevant. This includes education or nursery staff who identify a girl may be at risk of FGM because an older sister or female cousin has had the procedure.